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22 Cards in this Set

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What is a Change-of-Shift report?
a report given to nurses on the next shift.
Define a Chart.
A chart is a formal, legal document that provides evidence of a client's care.
Define Charting.
Charting is the process of making an entry on a client's record.
Define CBE.
(CBE) is Charting By Exception- a documentation system in which only significant findings or exceptions to norms are recorded.
What is another name for "client record"?
Chart
Define Discussion.
Discussion - an informal oral consideration of a subject by two or more health care personnel to identify a problem or establish strategies to resolve a problem.
What are some synonym for documenting?
Charting, Recording.
What is a Flowsheet?
A flowsheet is a record of the progress of a specific or specialized data such as vital signs, fluid balance, or routine medications; often charted in graph form.
A method of charting that uses key words or foci to describe what is happening to the client is known as what?
Focus charting
Define Kardex.
Kardex is the trade name for a method that makes use of a series of cards to soncisely organize and record client data and instructions for daily nursing care--especially care that changes frequently and must be kept up-to-date.
What do we call a descriptive record of client data and nursing interventions, written in sentences and paragraphs?
We this Narrative charting.
What is PIE?
PIE is an acronym for a charting model that follows a recording sequence of problems, interventions, and evaluation of the effectiveness of the interventions.
What is POMR?
POMR is an acronym that stands for Problem Oriented Medical Record.
Describe POMR.
In POMR data about the client are recorded and arranged according to the client's problems, rather than according to the source of the information.
What is a synomyn for POMR?
A syn. for POMR is POR shich stands for Problem-Oriented Record.
Define Progress notes.
Progress notes are chart entries made by a variety of methods and by all health professoinals involved in a client's care for the purpose of describing a client's problems, treatments, and progress toward desired outcomes.
What is a Record?
A record is a written communication providing formal, legal documentation of a client's progress.
Define Recording.
the process of making written entries about a client on the medical resord.
Describe a good Report?
whether oral or written, it should be concise, including pertinent information but no extraneous detail
What is SOAP besides something we use to wash our hands with?
An acronym for a charting method that follows a recording sequence of Subjective data, Objective data, Assessment, and Planning.
What type of recording is done where each person or department makes notations in a separate section or sections of the client's chart?
Source'oriented record.
What is a variance?
A variation or deviation from a critical pathway; goals not met or interventions not performed according to the time frame.